Healthcare Customer Service Representative Job at Insight Global in Remote

Position: Healthcare Customer Service Representative

Type: 6-Month Contract-to-Hire

Location: REMOTE - Must Site in One of the Following States - Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Virginia, Washington (state), West Virginia, or Wisconsin

Hours: 8am-6pm EST

Pay Range: 17-20/HR

Overview: We are seeking a dedicated Healthcare Customer Service Representative to join our team. This role involves assisting members with inquiries related to their insurance plans, eligibility, benefits, and claims. The ideal candidate will have a strong understanding of various insurance plan types and excellent communication skills.

Key Responsibilities:

Healthcare Basics

• Recognize and understand various insurance plan types, including Commercial, Individual Products, HIX, and Government Plans (Medicaid/Medicare).
• Familiarity with common insurance terminology and procedures.

Phone Skills

• Receive and respond to member inquiries via inbound calls using NICE inContact - Max Agent.
• Make outbound calls to members, vendors, and other departments.
• Follow established call flow processes for member interactions.
• Understand and apply protocols for using the language line for effective communication.

Eligibility and Enrollment

• Verify member status, including ID numbers and personal information, using Salesforce, CSC, and QNXT.
• Confirm member eligibility and plan effective dates.
• Manage member correspondence, including sending plan documents and updating demographics.

Provider Information

• Verify provider status (NPI, Tax ID) and understand provider types and specialties.
• Assess whether providers are Par or Non-Par and recognize specialty networks.

Website Assistance

• Educate members on using the Sentara/OHP website and assist in creating member accounts.
• Help members locate necessary forms and documents.

Benefits Administration

• Locate, interpret, and quote benefit information, including covered/excluded benefits and member out-of-pocket costs.
• Familiarity with various plan documents and protocols for coordination of benefits.

Authorizations

• Understand diagnosis codes (ICD 9-10) and procedure codes (CPT and HCPCS).
• Provide updates on authorization status and address member inquiries regarding pending or denied authorizations.

Claims Management

• Recognize and understand different claim types and statuses.
• Review claims details with members and assist with EOB inquiries.

Grievance and Appeals

• Initiate grievance and appeals requests over the phone and communicate with the G&A department as needed.

Collaboration

• Work closely with the Quality Team, L&D Team, and other departments to ensure high-quality service delivery.